Preparation and Practice of the Necessary Documents in Hospital for the “Act on Decision of Life-Sustaining Treatment for Patients at the End-of-Life” / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Six forms relating to decisions on life-sustaining treatment (LST) for patients at the end-of-life (EOL) in hospital are required by the “Act on Decision of LST for Patients at the EOL.” We investigated the preparation and creation status of these documents from the database of the National Agency for Management of LST. @*Materials and Methods@#We analyzed the contents and details of each document necessary for decisions on LST, and the creation status of forms. We defined patients completing form 1 as “self-determined” of LST, and those whose family members had completed form 11/12 as “family decision” of LST. According to the determination subject, we compared the four items of LST on form 13 (the paper of implementation of LST) and the documentation time interval between forms. @*Results@#The six forms require information about the patient, doctor, specialized doctor, family members, institution, decision for LST, and intention to use hospice services. Of 44,381 who had completed at least one document, 36,693 patients had form 13. Among them, 11,531, 10,976, and 12,551 people completed forms 1, 11, and 12, respectively. The documentation time interval from forms 1, 11, or 12 to form 13 was 8.6±13.6 days, 1.0±9.5 days, and 1.5±9.7 days, respectively. @*Conclusion@#The self-determination rate of LST was 31% and the mean time interval from self-determination to implementation of LST was 8.6 days. The creation of these forms still takes place when the patients are close to death.

Ethical and legal consideration on medical realities and ethical debates about withholding or withdrawing treatment in end-of-life care

It is natural for all human beings to die; hence, death is an inevitable event. However, advances in medical technology are changing the meaning of natural death. These advanced treatments provide the capability to intervene at the time of death and to reshape the circumstances around natural death, by sustaining human life. However, it is extremely difficult to judge when treatment is futile for the patient's best interests. It is therefore recommended to make time to discuss the concept of medical futility during the course of caring for a critically ill patient. Despite the expectations and efforts of the patient, the patient's family, and medical staff, the patient will eventually, have a ‘hopeless’ medical condition. Most discussions about decision-making in end-of-life treatment have neen ethical debates focused on the patient's self-determination and best interest in the context of concepts such as euthanasia or death with dignity. However, such discussions are insufficient for resolving the wide variety of circumstances that occur in clinical settings. Instead, the various ethical dilemmas inherent to end-of-life care should be approached by educating medical teams, patients, and their families about how to recognize medical futility. Furthermore, it is important to optimize the balance between the rights of patients and the responsibility of physicians.

Ethical and legal consideration on medical realities and ethical debates about withholding or withdrawing treatment in end-of-life care

It is natural for all human beings to die; hence, death is an inevitable event. However, advances in medical technology are changing the meaning of natural death. These advanced treatments provide the capability to intervene at the time of death and to reshape the circumstances around natural death, by sustaining human life. However, it is extremely difficult to judge when treatment is futile for the patient's best interests. It is therefore recommended to make time to discuss the concept of medical futility during the course of caring for a critically ill patient. Despite the expectations and efforts of the patient, the patient's family, and medical staff, the patient will eventually, have a ‘hopeless’ medical condition. Most discussions about decision-making in end-of-life treatment have neen ethical debates focused on the patient's self-determination and best interest in the context of concepts such as euthanasia or death with dignity. However, such discussions are insufficient for resolving the wide variety of circumstances that occur in clinical settings. Instead, the various ethical dilemmas inherent to end-of-life care should be approached by educating medical teams, patients, and their families about how to recognize medical futility. Furthermore, it is important to optimize the balance between the rights of patients and the responsibility of physicians.

Consensus guidelines for the definition of the end stage of disease and last days of life and criteria for medical judgment

In Korea, the Hospice, Palliative Care, and Life-sustaining Treatment Decision-making Act was enacted in February 2016 in order to ensure that the patient's self-determination in end-of-life care processes is respected. To enhance physicians' understanding of this act and to provide proper criteria for medical judgment in variety of clinical settings, consensus guidelines were published in November 2016. In this article, the characteristics of these guidelines and related issues regarding the definitions of ‘the end stage of disease’ and ‘last days of life’ and the criteria for medical judgment are presented and summarized. According to the guidelines, the term ‘end stage of disease’ refers to a state in which there is no possibility of a fundamental recovery and the symptoms are expected to worsen within months. The terms ‘the last days of life’ and ‘the final days of life’ refer to a state in which, despite treatment, the patient's condition is worsening and death is impending, with no possibility of recovery. The attending physician and another relevant specialist should both judge a patient's medical condition as either ‘end stage of disease’ for hospice/palliative care or ‘the last days of life’ for dying patient care according to the law. Caregivers should provide appropriate medical information to eligible patients for palliative or ‘end stage of disease’ care through advance care planning. Therefore, it is critically necessary that caregivers understand the legitimate process of hospice/palliative and dying patient care based on the patient's wishes and best interests. Physicians should apply these consensus guidelines to eligible patients considering their clinical course and the patients' wishes.

Consensus guidelines for the definition of the end stage of disease and last days of life and criteria for medical judgment

In Korea, the Hospice, Palliative Care, and Life-sustaining Treatment Decision-making Act was enacted in February 2016 in order to ensure that the patient's self-determination in end-of-life care processes is respected. To enhance physicians' understanding of this act and to provide proper criteria for medical judgment in variety of clinical settings, consensus guidelines were published in November 2016. In this article, the characteristics of these guidelines and related issues regarding the definitions of ‘the end stage of disease’ and ‘last days of life’ and the criteria for medical judgment are presented and summarized. According to the guidelines, the term ‘end stage of disease’ refers to a state in which there is no possibility of a fundamental recovery and the symptoms are expected to worsen within months. The terms ‘the last days of life’ and ‘the final days of life’ refer to a state in which, despite treatment, the patient's condition is worsening and death is impending, with no possibility of recovery. The attending physician and another relevant specialist should both judge a patient's medical condition as either ‘end stage of disease’ for hospice/palliative care or ‘the last days of life’ for dying patient care according to the law. Caregivers should provide appropriate medical information to eligible patients for palliative or ‘end stage of disease’ care through advance care planning. Therefore, it is critically necessary that caregivers understand the legitimate process of hospice/palliative and dying patient care based on the patient's wishes and best interests. Physicians should apply these consensus guidelines to eligible patients considering their clinical course and the patients' wishes.